International Perspectives on Adolescent and Young

Adult Drinking

Salme K. Ahlström, Ph.D., and Esa L. Österberg, M.Sc.

SALME K. AHLSTRÖM, PH.D., is a research professor, and ESA L. ÖSTER­BERG, M.SC., is a senior researcher, both in the Alcohol and Drug Research Group, National Research and Develop­ment Centre for Welfare and Health, Helsinki, Finland.

Alcohol consumption by adolescents and young adults varies greatly  in different countries and cultures,  in different population groups within a country, and over time. Analyses of per capita consumption  in different countries provide  some  information on drinking patterns of young people  in various countries. School­based surveys conducted  in a variety of European countries and in the United States offer more specific insight into the drinking behavior of this age group. Such surveys have analyzed variables  such as age of onset of drinking;  lifetime  frequency of drinking; drinking to intoxication; frequency, amount, and timing of current drinking; and drinking consequences. These  studies have demonstrated  that drinking patterns of young people  in,  for example, Scandinavian, Anglo­Saxon, and Mediterranean countries vary greatly. Further analyses have explored the influence of social norms and related factors as well as alcohol availability and pricing on alcohol consumption among adolescents and young adults. The generalizability of the findings  is  limited, however, by  the  fact  that most  studies have been conducted  in  the United States and Europe. KEY WORDS: young adult; adolescents; AOD (alcohol and other drug) consumption; AOD use frequency; AOD intake per occasion; AOD use pattern; age of AODU (alcohol and other drug use) onset; heavy drinking; AOD abstinence; factors determining AOD demand; AOD effects and consequences; international AODR (alcohol and other drug related) problems; international aspects; ethnic differences; cultural patterns of drinking; gender differences; minimum drinking age laws; prevention through decreasing availability and accessibility; World Health Organization (WHO); European School Survey Project on Alcohol and Other Drugs (ESPAD)

Studies conducted in various coun­tries have demonstrated that both the frequency of drinking alcoholic

beverages and the amount of alcohol consumed per person or per occasion vary greatly among different countries and cultures, among different population groups within a given country, and for each population over time. Similarly, the rates of alcohol­related problems vary greatly among different countries and among different population groups. These differences are found not only for adult drinkers but also for adoles­cents and young adults.

One useful measure that can easily be determined in many countries is the total alcohol consumption of the popu­

lation, which can be converted to average per capita consumption. This variable is related to the prevalence of heavy alcohol use and also is an important indicator of the prevalence of alcohol­related problems (Bruun et al. 1975; Edwards et al. 1994). The relationship between average per capita consump­tion and the level of alcohol­related problems in a population is influenced by the following factors: 

• The number of drinkers in the pop­ulation and their drinking habits (Babor et al. 2003). For example, if total alcohol consumption can be attributed to only 20 percent of the population, who mostly drink on the

weekends (and the remaining popu­lation does not drink), the prevalence of heavy drinking and of alcohol­related problems will be different than if alcohol consumption can be attributed to 90 percent of the population who generally have only one drink per day.

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• The drinking culture and attitudes toward drinking and alcohol­related problems. “Harmful” drinking and alcohol­related problems are in part culturally defined—that is, a behavior (e.g., drinking to intoxication) con­sidered problematic in one culture may not be thought of as problem­atic in another culture.

• Overall historical, cultural, economic, and social circumstances that affect many areas related to alcohol con­sumption. For instance, if drinking habits are similar in two countries but people in one of those countries are significantly less likely to own a car, then the frequency of drunk driving and the proportion of alcohol­related deaths among all traffic fatal­ities will differ greatly between the two countries.

• Alcohol control measures and their enforcement. For instance, increases in the legal drinking age and effective enforcement of the new age limit will lead to lower alcohol consump­tion levels and fewer alcohol­related problems among young adults and adolescents.

The relationships between alcohol consumption and alcohol­related prob­lems, as well as the factors that influence these relationships, apply to both adult and adolescent drinking. When trying to compare adolescent or young adult alcohol consumption across countries or cultures, however, researchers must keep in mind that the definitions of these two developmental stages can vary according to the cultural and historical background of the society under inves­tigation. Broadly defined, adolescence and young adulthood include the period of transition from childhood to adult­hood. It is the time when a person acquires the skills needed to cope with the emotional, physical, social, and economic separation from parents. Ideally, it also is the time when a person paves the way for establishing his or her own family, raising children, and par­ticipating in social and work life as well as leisure time activities as an independent individual. Because these developments

may occur at different ages in different cultures, it is difficult to define adoles­cence and young adulthood in terms of exact ages. For practical purposes, in most Western industrialized societies, adoles­cence is defined as ages 14 through 18 and young adulthood as ages 19 through 25 (Ahlström 2000). In some studies, even 29­year­olds have been considered young adults (Rehm et al. 2001).

After a brief review of alcohol con­sumption patterns in the entire popula­tion (which to a certain extent also reflect consumption patterns by younger people), this article provides an interna­tional perspective on alcohol consump­tion among adolescents and young adults and examines gender differences, abstinence rates, the amount and fre­quency of drinking, as well as drinking to intoxication. This discussion considers not only the actual drinking patterns but also the drinking contexts (i.e., the time and place of drinking and the nature of the drinking occasion). It is important to keep in mind, however, that the information on drinking patterns usually comes from survey studies, which can differ greatly in how different aspects of drinking patterns are defined and measured (Simpura and Karlsson 2001). Furthermore, most of the available research data were obtained in the developed countries, which may limit the generalizability of these research findings to adolescent and young adult drinking in other areas of the world. 

International Comparisons of Adult Alcohol Consumption Patterns

Drinking alcohol is a social behavior in the sense that it is something young people learn and practice with other members of their culture (Edwards et al. 1994). Drinking patterns among adolescents and young adults in any country or culture consequently are related in many ways to the drinking patterns of the entire population (Room 2004). Therefore, a global review of per capita alcohol consumption and general drinking patterns also gives a first rough description of the differences in the amounts and patterns of adolescent

and young adult drinking in different parts of the world. Adolescent and young adult drinking behaviors may show some systematic deviation from adult drinking behaviors in a given culture, however, because of differences in living conditions between adolescents/ young adults and the adult population and because of the influences of inter­national youth culture and mass media.

One source of information on alcohol consumption and its consequences in various areas of the world is the World Health Organization (WHO). For sur­veying purposes (e.g., to estimate the global burden of disease), WHO has divided the world into 15 geographical areas based on adult and infant mortal­ity. WHO also has used these areas to estimate the levels of alcohol con­sumption and proportions of drinkers around the globe.1 However, countries within these 15 areas are not always uniform with regard to alcohol con­sumption and drinking habits. For example, Iceland and Norway, with a total alcohol consumption of about 7 liters per person age 15 and older, belong to the area “Europe A,” where the average alcohol consumption is 13 liters (i.e., almost twice that in Iceland or Norway). Despite these kinds of problems, the WHO data help to broadly characterize the levels and trends in alcohol consumption and drinking pat­terns in different parts of the world.

General Trends in Total Alcohol Consumption

Rehm and colleagues (2003) conducted an international comparison of average alcohol consumption in people age 15 and older around the world using the WHO data. These analyses found the following:

• Average alcohol consumption was highest in Europe, the Americas, and established market economies such as Australia, Japan, and New Zealand, although there were exceptions (e.g., the Muslim countries of the former

1 These data are derived primarily from population­weighted averages of country estimates, but in many cases the figures include a substantial element of extrap­olation and expert judgment (Babor et al. 2003).

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Soviet Union and Yugoslavia and the least developed countries in South and Central America). 

• Average alcohol consumption gener­ally was lower in Africa and Asia.

• Alcohol consumption was particu­larly low in the Muslim countries in the eastern Mediterranean region and on the Indian subcontinent.

Other studies have examined changes in per capita or per adult alcohol con­sumption since the mid­1970s (Babor et al. 2003) and have found that: 

• Alcohol consumption appears to have declined in many countries with previously high alcohol consump­tion, particularly in the traditional wine­producing and wine­drinking countries of Europe (i.e., France, Italy, Portugal, and Spain) but also in the wine­producing countries of South America.

• In many other established market economies, such as Canada and the United States, a smaller but still sig­nificant decrease in total alcohol consumption has occurred over the same period.

• In most countries of the Americas and Africa and in the eastern Mediterranean countries, alcohol consumption has been constant or slightly decreasing during recent decades. 

• Alcohol consumption appears to have increased the most in Asian countries.

• Some developed countries (e.g., Denmark, Finland, Ireland, and Japan) have countered the trend toward decreasing alcohol consump­tion; in fact, consumption there has increased. 

Proportions of Drinkers

The proportion of people who drink any alcohol varies greatly among differ­ent countries. In general, the highest

proportion of drinkers is found in Europe, Australia, and New Zealand, where 80 to 90 percent of all adults are drinkers (Rehm et al. 2003). In the Western Pacific, 80 to 90 percent of all men are drinkers. In the Americas, about two­thirds of adults are drinkers. For instance, the share of drinkers is 73 percent in Canada and 65 percent in the United States (Babor et al. 2003). In African countries, around half of the men and one­third of the women drink alcohol. In the rest of the world, only a minority of adults are drinkers. 

In all countries, men are more likely to drink alcohol than are women. The differences between men and women in the proportion of drinkers are particu­larly marked in China and Southeast Asia. Women are especially likely to be abstainers in the Indian subcontinent and Indonesia as well as in the Middle East (Rehm et al. 2003).

Differences in Drinking Patterns

Many studies (primarily based on survey data) have analyzed drinking patterns around the world. These studies consis­tently have found significant differences in drinking patterns between men and women, between younger and older people, and often among ethnic or reli­gious groups. For example, Ahlström and colleagues (2001a) found that, on average, men drink significantly more than women do. In many countries, men account for 70 to 80 percent or more of the total alcohol consumption, and in some developing countries, men’s share of overall alcohol consumption is even greater. For instance, survey data from China indicate that men consume about 95 percent of all alcohol (Babor et al. 2003).

Alcohol consumption also is unevenly distributed among the drinking popu­lation in any country—that is, in all societies, most of the alcohol is con­sumed by a relatively small proportion of drinkers. For example, in the United States, the top 20 percent of drinkers consume almost 90 percent of all alcohol (Greenfield and Rogers 1999). And in China, the top 12.5 percent of the drinkers (corresponding to 7.5 percent of the population) have been estimated

to account for 60 percent of total alco­hol consumption (Wei et al. 1999). In general, the proportion of drinkers who account for most of the alcohol consumption probably is smaller in countries with low per capita alcohol consumption—that is, in these coun­tries alcohol consumption is more con­centrated (Edwards et al. 1994).

Intoxication and Harmful Drinking

Countries also vary in how often people drink to intoxication, how intoxicated people get, and how people behave while intoxicated. Generally, men are more likely than women to consume large quantities of alcoholic beverages or drink to intoxication (Babor et al. 2003). Also, the proportion of heavy drinkers and the frequency of heavy­drinking occasions are higher among men than among women. Consequently, patterns of harmful drinking 2 are more common in men than in women. Some evidence suggests that this phenomenon may be even more pronounced in devel­oping countries (Room et al. 2002).

According to WHO’s data on the global burden of disease, people in the former socialist countries of Eastern Europe, in Middle and South America, and in parts of Africa exhibit the most detrimental drinking patterns. For example, in these countries, drinking to intoxication is a characteristic medi­ator between alcohol consumption and alcohol­related morbidity, mortality, and social harms. Conversely, drinking patterns appear to be least detrimental in Western Europe, as represented by the patterns found in the wine­producing countries of southern Europe, where people primarily consume wine with meals and do not drink to intoxication (Rehm et al. 2003).

2 Harmful drinking refers to any drinking pattern where drinking causes immediate harm to the drinker or others, including physical harm (e.g., resulting from alcohol­related unintended injuries and car crashes), social harm (e.g., arguments with family members or others), economic harm (e.g., lost property), or legal harm (e.g., conviction for drunk driving).

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Drinking Patterns of Adolescents and Young Adults

The drinking patterns of people in var­ious age groups are difficult to compare internationally because population sur­veys conducted in different countries often use different age groupings and varying measures of alcohol consump­tion levels. Furthermore, most surveys that compare drinking in various age groups have been conducted in the established market economies of Europe and North America, and their findings do not always apply to other regions of the world. Nevertheless, two common findings have emerged from these stud­ies (Babor et al. 2003): (1) abstinence is more prevalent in older age groups than among young adults, and (2) intoxication is more frequent among young adults than older people.

One survey that has provided basic information on adolescents’ alcohol consumption in various European coun­tries is the European School Survey Project on Alcohol and Other Drugs (ESPAD) (Hibell et al. 2004). This multinational study of drinking habits and drug use among 15­ to 16­year­old European students was first conducted in 1995, and a second survey followed in 1999. For the most recent data col­lection, conducted in 2003, students from 35 European countries filled out anonymous self­administered in­school questionnaires. Sample sizes, which were designed to be nationally representa­tive, ranged from 555 in Greenland to almost 6,000 in Poland. The findings of this and other relevant surveys are summarized in the following sections.

Age at Onset of Drinking and Prevalence of Abstinence

Both the long­term and short­term health effects of alcohol consumption depend at least in part on the age when the person begins to consume alcohol. For example, results from a U.S. survey indicate that compared with those who begin drinking at a later age, respondents who begin drinking in their teenage years are more likely during late adoles­cence and adulthood to experience

alcohol­related unintentional injuries (e.g., motor vehicle crashes, falls, burns, and drownings) and to be involved in fights after drinking (Hingson et al. 2000). Furthermore, early onset of reg­ular alcohol consumption is a signifi­cant predictor of lifetime alcohol­related problems, at least in some Western countries (Chou and Pickering 1992; Grant and Dawson 1997; Kraus et al. 2000; Pulkkinen et al. 2003). However, it is not clear whether starting to drink at an early age actually causes alcohol­related problems and alcohol use disor­ders or whether it simply indicates an existing vulnerability to alcohol use disorders (Dawson 2000).

In the United States, the average age of first­time use of alcohol is about 13 years. In contrast, in a survey conducted in 23 European countries in the late 1990s, more than half of 11­year­olds reported having tasted alcohol (Jernigan 2001). Still, at the beginning of adoles­cence, the abstinence rate in all European countries is high compared with the adult abstinence rate.

In the ESPAD study, the highest absti­nence rate among European youths, 36 percent, was found in Iceland (table 1). In the other Nordic alcohol­monopoly countries Finland, Norway, and Sweden (i.e., former spirit­consuming countries3), about 20 percent of the 15­ to 16­year­old students had not consumed any alcoholic beverages during the previous 12 months. Also, in some of the south­ern European wine­preferring coun­tries, many of which are characterized as having the highest alcohol consump­tion in Europe, abstinence rates among youth were high (e.g., 26 percent in Portugal, 25 percent in Spain, and 20 percent in France) (see table 1). Conversely, the abstinence rate in Greece—also a wine­preferring country— was only 9 percent. Equally low or even lower abstinence rates also were found in beer­preferring countries such as Austria, the Czech Republic, Denmark, Germany, and the United Kingdom (Hibell et al. 2004). All of these absti­nence rates are substantially lower than in the United States, where 41 percent of students reported not having con­sumed any alcoholic beverages during the last 12 months (Johnston et al. 2004).

Between adolescence and the onset of adulthood, abstinence rates decreased in most countries, and were about the same for people at age 25 as for middle­aged adults. Moreover, in many coun­tries, differences in abstinence rates between males and females were smaller at age 15 than at age 25 (see Hibell et al. 2004; Rehm et al. 2001). In fact, among 15­ to 16­year­old students, females in many countries showed lower abstinence rates than males (table 1).

Lifetime Frequency of Drinking

The frequency of alcohol consumption among adolescents is still relatively low. In almost all ESPAD countries and in the United States, less than half of 15­to 16­year­old students were consid­ered frequent drinkers—that is, they had consumed alcohol on 40 or more occasions during their lifetime (see table 2) (Hibell et al. 2004). The only country where 50 percent of adolescents reported such a frequency of alcohol consumption (i.e., were frequent drinkers) was Denmark. Otherwise, the countries with the highest proportion of frequent drinkers were Austria, the Czech Republic, the Netherlands, Ireland, and the United Kingdom. The lowest proportions of frequent drinkers were found in Greenland, Iceland, Norway, Portugal, and Turkey. In most countries, more boys than girls reported a lifetime prevalence of drinking at least 40 times.

Drinking to Intoxication

In many cultures, drinking to intoxica­tion is particularly characteristic of ado­lescents and young adults, and young males are more likely to drink to intox­ication than young females (Currie et al. 2004; Hibell et al. 2004; Kuntsche et al. 2004).

According to the ESPAD study, it is not uncommon for students to drink

3 Although some decades ago there seemed to be relatively clear distinctions among European countries with respect to the beverages of preference—that is, northern European countries were classified as spirit­consuming, Anglo­Saxon and Central European countries were considered beer­consuming, and southern European countries were consid­ered wine­consuming—drinking patterns in many countries have changed, and these distinctions have been blurring in recent decades.

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to intoxication, although the prevalence of drunkenness varies considerably across the countries (see table 2). Thus, in the Nordic and Baltic countries as well as in Austria, the Czech Republic, Ireland, and the United Kingdom, nearly 20 percent or more of students reported having been drunk at least 20 times in their lives, compared with about 5 percent or less of students in most southern European countries and in Belgium and the Netherlands (Hibell et al. 2004). In other central European and in eastern European countries as well as in the United States, the proportions of students who reported having been drunk at least 20 times were intermediate.

Frequency and Amount of Drinking

The ESPAD study also compared the number of drinking occasions and the amounts consumed per occasion by adolescents in the different countries. These analyses found that in the wine­producing countries (i.e., France, Greece, Italy, and Portugal), adolescents’ alcohol consumption can be characterized as fairly frequent but modest (Ahlström et al. 2001b). In the Nordic countries (i.e., Finland, Iceland, Norway, and Sweden), in contrast, alcohol consumption can be characterized as seldom but to intox­ication. In the beer­preferring nations of Denmark, Ireland, and the United Kingdom, the students drink frequently and to intoxication (see the figure). However, this is not the case in all beer­preferring countries (e.g., Germany, the Czech Republic, and Belgium), demon­strating that drinking habits are not properties of alcoholic beverages and that certain kinds of beverages may be used in different ways. Nevertheless, the prevailing drinking patterns exhibit some relationship with the preferred alcoholic beverages.

Time of Alcohol Consumption

One way to describe drinking patterns is to investigate how alcohol consump­tion is integrated into everyday activities (e.g., consumption with meals) (Ahlström­Laakso 1976). In many wine­producing countries, drinking is an integral part of meals. For instance, Italian adults

rarely drink between meals. In contrast, in countries such as the United Kingdom, the United States, and the Nordic countries, most people drink at times other than meals.

The drinking patterns of adolescents and young adults in the various countries mirror those of the adults. Thus, the prevalence of intoxication (which typi­cally results from alcohol consumption outside of meals) was much lower among

adolescents in wine­producing European countries than among adolescents in Anglo­Saxon and Nordic countries (Currie et al. 2004; Hibell et al. 2004). In recent years, however, people in Mediterranean countries, especially young people, have begun to consume wine at times other than meals (Nahoum­Grappe 1995), and adolescents in these countries have begun to drink to intoxication more frequently. These

Table 1 Abstinence Rates Among European and American 15­ and 16­Year­Olds During the Last 12 Months*

Country All Students (%) Males (%) Females (%)

Austria 7 8 6 Belgium Bulgaria Croatia

14 14 18

13 13 15

15 14 21

Cyprus Czech Republic Denmark

21 5 5

16 5 4

26 5 5

Estonia 13 14 11 Faroe Islands 24 24 24 Finland 20 22 19 France 20 18 22 Germany Greece

7 9

7 7

7 10

Greenland 27 32 23 Hungary Iceland

16 36

16 38

16 35

Ireland 12 14 10 Isle of Man 6 8 4 Italy Latvia

18 13

15 14

20 12

Lithuania 6 6 6 Malta 10 9 11 Netherlands 15 14 15 Norway Poland

24 15

26 12

21 17

Portugal Romania

26 20

24 16

28 23

Russia (Moscow) Slovak Republic Slovenia

14 10 17

18 10 15

11 9

19 Spain Sweden

25 23

26 23

24 23

Switzerland 12 12 13 Turkey Ukraine

65 16

60 17

72 15

United Kingdom United States

9 41

10 43

8 39

*Data on European adolescents was taken from the 2003 European School Project on Alcohol and Other Drugs (ESPAD).

SOURCE: Hibell et al. 2004.

Alcohol Research & Health 262

International Perspectives

observations suggest that moderate, controlled drinking in the wine­producing countries is being replaced by a more irregular pattern of drinking leading to inebriation (Grosso 2004). Moreover, drunken behavior has become more frequent on festive occasions. Thus, the drinking behavior of adolescents from wine­producing countries is beginning

to resemble the behavior of adolescents from countries such as Denmark, Finland, and the United Kingdom.

Consequences of Drinking

Most alcohol­related problems that affect young people do not result from chronic heavy drinking but from occa­

sional heavy drinking and intoxication. Only a minority of young adults— most of them men—drink heavily on a regular basis, thereby increasing their risk of encountering health problems typically associated with chronic alcohol consumption (e.g., liver disease). How­ever, even young people (including the majority of young women) who generally

Table 2  Prevalence of Various Indicators of Drinking Behavior Among European and American 15­ and 16­Year­Olds*

Lifetime Alcohol  Binge Consumption Intoxication Drinking

Percent who had  Percent who had  Percent who had  Percent who had consumed alcohol  been intoxicated  been intoxicated  consumed at least 5 at least 40 times  at least 20 times  at least 3 times in  drinks in a row at least 3

Country in their lives in their lives the past 30 days times in the past 30 days

Austria 48 21 17 NA** Belgium 36 7 8 22 Bulgaria 27 10 10 21 Croatia 27 9 8 15 Cyprus 21 2 1 10 Czech Republic 46 18 13 18 Denmark 50 36 26 24 Estonia 32 26 17 20 Faroe Islands 32 24 18 19 Finland 20 26 16 15 France 22 3 3 9 Germany 37 12 10 28 Greece 35 3 3 11 Greenland 13 21 19 19 Hungary 21 11 9 8 Iceland 14 16 10 11 Ireland 39 30 26 32 Isle of Man 45 29 23 27 Italy 24 5 7 13 Latvia 26 14 8 22 Lithuania 38 21 12 13 Malta 33 4 5 25 Netherlands 45 6 7 28Norway 15 14 12 24 Poland 27 10 10 11 Portugal 14 3 3 16 Romania 18 3 3 11Russia 39 15 11 17 Slovak Republic 34 14 11 15 Slovenia 25 15 12 22 Sweden 17 17 9 25 Switzerland 27 10 9 15 Turkey 7 1 1 5 Ukraine 22 18 16 22 United Kingdom 43 27 23 27 United States 12 7 7 9

*Data on European adolescents was taken from the 2003 European School Project on Alcohol and Other Drugs (ESPAD). **NA = no data available

Source: Hibell et al. 2004.

Vol. 28, No. 4, 2004/2005 263

1

drink in moderation may occasionally drink heavily, thereby increasing their risk for certain adverse effects. For example, alcohol interferes with cogni­tive, perceptual, and motor skills and therefore can contribute to uninten­tional injuries and deaths, particularly after heavy alcohol consumption. In fact, in many societies, alcohol­related fatalities are particularly common among young adults and contribute substantially to alcohol­related mortality (Ahlström 2002). This particularly high mortality rate is attributable in part to the drink­ing patterns of young adults (i.e., drinking heavily or to intoxication) and in part to their lack of experience with and tolerance for alcohol, which may make them more likely, for example, to be involved in alcohol­related traffic crashes than more experienced drinkers (Ahlström 2002).

In the established market economies of Europe, the proportion of alcohol­related deaths is higher among young men than among young women. Among

15­ to 29­year­olds, 12.8 percent of all deaths among males and 8.3 percent of all deaths among females have been estimated to be attributable to alcohol, indicating that alcohol­related deaths account for a considerable amount of mortality in young Europeans (Rehm et al. 2001). Traffic crashes are the main cause of alcohol­related deaths for both genders, followed by self­inflicted injuries; alcohol­related chronic diseases are not common causes of death in this age group. Both the average volume of alcohol consumption and patterns of drinking influence the rate of alcohol­related deaths.

Young adults are susceptible not only to alcohol­related health problems (i.e., deaths and injuries) but also to alcohol­related social problems. In fact, for any given level of drinking, young adults report more social problems than do middle­aged adults. These alcohol­related social problems include problems with family, friends, and at work; financial difficulties; legal prob­

lems, such as property damage, public disturbance, violence, or sexual assault; and other risk­taking behavior. The probability of young people suffering such social consequences increases with their level of drinking.

Factors Affecting Drinking by Adolescents and Young Adults

In general, a person’s drinking behavior is affected by two groups of factors (Quigley and Marlatt 1996; also see Jackson et al. 2005):

• Internal factors, such as gender, personality factors, and biologi­cal traits (e.g., certain genetic predispositions).

• External factors, such as social norms and the physical availability and prices of alcoholic beverages.

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Frequency of drinking and of getting drunk during the last 30 days among European and American 15­ and 16­year­olds, 2003. Data on European adolescents were taken from the 2003 European School Project on Alcohol and Other Drugs (ESPAD).

SOURCE: Hibell et al. 2004.

Alcohol Research & Health 264

International Perspectives

(For more information on genetic factors that influence drinking behavior, see the article by Rose in this issue. For discussion of social and other environ­mental factors that influence alcohol consumption by young adults, see the articles by White and Wagenaar and colleagues.)

Gender Differences

Gender and age are important factors affecting drinking behavior. In almost every society, young adult males drink more often than young adult females. During adolescence, drinking patterns are less differentiated by gender, and at the onset of young adulthood, females may even drink more frequently than males, partly because females typically mature earlier than males and partly because they do not yet have family bonds and responsibilities. Once they reach and pass through young adult­hood, however, young women tend to consume less alcohol, drink less fre­quently, and get drunk less often than young men (Ahlström et al. 2001a).

The ESPAD study as well as some other analyses have demonstrated that many countries now show a conver­gence of boys’ and girls’ drinking pat­terns that blurs the distinction between the genders (Currie et al. 2004; Hibell et al. 2000, 2004; Johnston et al. 2000). For example, although consumption of beer and spirits still is more frequent among boys than girls in most ESPAD countries, prevalence rates for con­sumption of spirits are equal or almost equal between the sexes in nearly half of the countries. Likewise, the frequency of intoxication is similar for both gen­ders in many ESPAD countries (Hibell et al. 2004). The convergence of drink­ing patterns is especially obvious in the Nordic countries, Ireland, the United Kingdom, and the United States. In the eastern and southern European countries, however, large gender differ­ences still exist.

Social Norms and Other Social Factors

Social norms about when, how often, and at what level drinking is considered acceptable vary among different countries

or even among population subgroups within a country, and they may change over time. Other social factors, such as the context of the drinking occasion, also can influence people’s drinking behavior. In a Dutch study investigating the factors contributing to young adults’ heavy drinking in public during week­ends, social norms condoning alcohol consumption and drinking occasions characterized by socializing were identified as the most important factors (Oostveen et al. 1996). Modeling was the third most influential variable, but direct social pressure had only minimal influence.

Thus, it appears that for young adults, drinking not only is a matter of personal experimentation but also can reflect a desire to fit in with peers and others (Ahlström 2000). Consistent with this hypothesis, evidence suggests that the most reliable predictor of ado­lescents’ drinking behavior is the drink­ing behavior of their friends, followed by the drinking behavior of their sib­lings. Other family factors—such as parent–child relationships, communi­cation, and parenting practices—also significantly influence the drinking behavior of adolescents (Ahlström 2002).

Considerable evidence suggests that drinking patterns for all adults also depend on education, social class, occupation, employment status, place of residence, race or ethnicity, and reli­gion. However, few studies have inves­tigated the influence of these factors on young adults. One comparative study conducted in nine European countries examined the influence of marriage, parenthood, and employment on drinking behavior. These transitions tend to occur during early adulthood and demand the adoption of new social roles. The study found that parenthood was profoundly and consistently associ­ated with women’s drinking patterns— that is, women who had children, par­ticularly young mothers, consumed less alcohol than did women without children (Ahlström et al. 2001a). In the United States, religion also is an important factor affecting the age and onset of drinking. The importance of religion is further highlighted by the low alcohol consumption levels and high rates of abstinence in Muslim countries.

The influence of any social factor can differ profoundly among various countries. For example, in some coun­tries a person’s place of residence (e.g., a rural or urban area) has been shown to influence what type of beverage he or she primarily consumes. In wine­producing countries wine consumption is usually more popular in rural areas, but in the Nordic countries wine is con­sumed primarily in urban areas. This is explained for the most part by the fact that in wine­producing countries wine is a traditional drink with meals, whereas in the Nordic countries wine drinking is associated with modern living styles (Simpura and Karlsson 2001). 

Alcohol Availability and Pricing

Most countries have a minimum legal drinking age (MLDA) for purchasing, selling, or consuming alcoholic bever­ages. In most European countries, the MLDA is 18 years or less (see table 3). Several other countries—such as the United States, Egypt, Indonesia, Micronesia, Palau, Samoa, and the Solomon Islands—do not allow people to purchase, sell, or consume alcoholic beverages before the age of 21 (Jernigan 2001; WHO 2004). In many countries, the MLDA is the same for all alcoholic beverages, but in countries that have different age limits for different beverage types, the age limits usually are lower for beer and wine than for distilled bever­ages (Österberg and Karlsson 2002). In most countries, MLDAs are the same for off­premise and on­premise sales.

Alcohol taxation and high alcohol prices as well as strict regulation of physical alcohol availability (i.e., sale of alcoholic beverages only in limited locations or at certain times) are power­ful policy tools for controlling alcohol consumption (Babor et al. 2003). Although such measures affect the entire population, some studies have found that high alcohol prices particularly affect adolescents and young adults, who in many societies have fewer economic resources than older adults (Williams et al. 2005).

Evidence also suggests that the amount of money available to people influences the frequency of drinking. For example,

Vol. 28, No. 4, 2004/2005 265

Rahkonen and Ahlström (1989) ana­lyzed trends in drinking habits among Finnish adolescents between 1973 and 1987. They found that drinking fre­quency decreased at the beginning of the 1980s but then began to increase by 1983. This rise was explained by increased alcohol availability and by an increase in money available to adolescents for their leisure time activities. Similar results were obtained in a later study among Finnish students (Lintonen et al. 2000).

To assess the effectiveness of measures restricting alcohol availability in limiting alcohol consumption by adolescents,

Grossman and colleagues (1995) com­pared the effects of alcohol pricing policies and changes in MLDA. These investigators demonstrated that both types of measures impacted alcohol use and mortality from alcohol­related motor vehicle crashes, although higher taxes on alcohol were more effective at reduc­ing adolescent drinking than imple­mentation of a uniform MLDA of 21.

Summary and Discussion

Alcohol consumption is a social behav­ior, something people learn from and

practice with other members of their culture (family, peers, etc.). Consequently, the drinking behavior of adolescents and young adults in any country or culture is related to the drinking behavior of the whole population. International studies have demonstrated that adult drinking patterns vary greatly among different countries and cultures over time and between different population groups within a given country. Speaking very generally, the frequency and amount of alcohol consumption are highest in Europe, North America, and other coun­tries with established market economies; lower in Africa and Asia; and particularly

Table 3  Minimum Legal Drinking Ages (MLDAs) for Off­Premise and On­Premise Sales of Various Types of Alcoholic Beverages in European Countries

Off­Premise On­Premise

Country Beer  Wine  Spirits Beer Wine Spirits

Austria 16 16 18 16 16 18 Belgium —* — 18 16 16 18 Bulgaria 18 18 18 18 18 18 Cyprus NA** NA NA NA NA NA Czech Republic 18 18 18 18 18 18 Denmark 16 16 16 18 18 18 Estonia 18 18 18 18 18 18 Finland 18 18 20 18 18 18 France 16 16 16 16 16 16 Germany 16 16 18 16 16 18 Greece — — 18 — — 18 Hungary 18 18 18 18 18 18 Iceland 20 20 20 20 20 20 Ireland 18 18 18 18 18 18 Italy 16 16 16 16 16 16 Latvia 18 18 18 18 18 18 Lithuania 18 18 18 18 18 18 Luxembourg — — — 18 18 18 Malta 16 16 16 — — — Netherlands 16 16 18 16 16 18 Norway 18 18 20 18 18 20 Poland 18 18 18 18 18 18 Portugal 16 16 16 16 16 16 Romania 18 18 18 18 18 18 Slovak Republic 18 18 18 18 18 18 Slovenia 15 15 15 15 15 15 Spain 16 16 16 16 16 16 Sweden 18 20 20 18 18 18 Switzerland 16 16 18 16 16 18 Turkey 18 18 18 18 18 18 United Kingdom 18 18 18 16 16 18

*— = no legal age limit **NA = no data available SOURCE: WHO 2004.

Alcohol Research & Health 266

International Perspectives

low in the Muslim countries of the east­ern Mediterranean region and the Indian subcontinent. In recent decades, alcohol consumption has decreased especially in southern Europe and increased in Asia.

Despite its similarities to adult drink­ing, alcohol consumption by adolescents and young adults has some special characteristics because the way of life and living conditions of 14- to 25-year­olds in any culture differ somewhat from those of older adults. For example, the mass media (particularly the adver­tising industry), the Internet, and inter­national youth cultures also affect the drinking patterns of adolescents and young adults (Unger et al. 2003; Carroll and Donovan 2002).

One difference between adolescent/ young adult drinking patterns and adult drinking patterns concerns gender dif­ferences. In almost all cultures, men abstain less frequently than women and drink more frequently and in greater quantities than women. Among adoles­cents and young adults, especially at the onset of adolescence, however, these gender differences are less prominent or do not exist at all. Moreover, in many cultures, drinking to intoxication is more characteristic of adolescent and young adult drinking than of drinking by older adults. Finally, most of the alcohol-related problems that affect adolescents result from periodic heavy drinking and intoxication rather than from chronic alcohol consumption, because relatively few adolescents drink heavily on a regular basis. In contrast, older adults more frequently experience the adverse health effects (e.g., liver dis­ease) that result from long-term alcohol consumption.

Because most of the information researchers have acquired about the drink­ing patterns of adolescents and young adults is based on data obtained in European and North American countries, global comparisons of drinking patterns are difficult to make. In addition, less information is available on young adults than on adolescents, who, through school-based surveys, can be accessed more easily. To address these limitations and to allow for truly global and reliable comparisons of drinking patterns in adolescents and young adults, future

studies should focus more on regions outside North America and Europe. Such analyses also could reveal characteristic patterns in the factors affecting adolescent and young adult drinking behavior. Finally, studies following participants over time (i.e., longitudinal studies) are needed to better evaluate the findings of one-time cross-sectional studies.

The generalizability of existing research on the effects of alcohol pricing on adolescent and young adult drinking is limited because most of these studies have been conducted in the United States. Recent price decreases in Europe, especially in the Nordic countries, however, will provide researchers with an opportunity to study whether changes in price particularly affect alcohol con­sumption by adolescents and young adults in other countries as well. ■

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